Provider Demographics
NPI:1063176071
Name:MASTERPIECE BEHAVIOR SERVICES
Entity type:Organization
Organization Name:MASTERPIECE BEHAVIOR SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SETH
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA, LBA
Authorized Official - Phone:318-548-1589
Mailing Address - Street 1:2100 FLOYD PARK DR STE 2
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-6648
Mailing Address - Country:US
Mailing Address - Phone:318-548-1589
Mailing Address - Fax:
Practice Address - Street 1:2100 FLOYD PARK DR STE 2
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-6648
Practice Address - Country:US
Practice Address - Phone:318-548-1589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-26
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1104392034Medicaid